Patient Safety: IHI PS 201 Root Cause Analyses and Actions
1. RCA2 can be useful in health care because:
(A) It holds people accountable for their actions.
(B) It helps to identify system failures that can be corrected.
(C) It helps to assess the potential risk of introducing a new idea or process.
(D) All of the above: correct answer- B
RCA2 makes health care safer by focusing on systems failures and
improving processes. It does not blame individuals for their actions
and is not a method for enforcing accountability. It is not a method for
assessing the risk of introducing a new idea or process.
2. Mr. Reynolds, a 75-year-old man, recently suffered from a wrong-site
surgery. An RCA2 team is exploring what happened. They consider charac-
teristics of the patient and staff members. According to Charles Vincent,
what other areas should they consider?
(A) Team factors
(B) Work environment
(C) Institutional context
(D) All of the above: correct answer- D
1/7
,The best answer is all of the above. A wide range of factors influence
medical outcomes. Charles Vincent lists seven categories these
factors, including: patient characteristics, task factors, individual staff
member characteristics, team factors, work environment,
organizational and management factors, and institutional con- text.
3. Which of the following scenarios would most likely call for RCA2?
(A) An occupational therapist quits after only three days on the job.
(B) A physician is convinced that there is a better way to deliver pain
medica- tions on her unit.
(C) A social worker catches a patient who is falling out of bed.
(D) An administrator needs to develop a balanced budget.: correct answer-
C
RCA2 is important to address adverse events as well as near misses,
such as the near-fall in answer choice C, that indicate a potential for
harm to patients. Although the other options may represent
opportunities for improvement, they are not indicative of an imminent
threat to patient safety and would not trigger RCA2.
2/7
,4. In regard to RCA2, "The chance of a specific event occurring; measured
in terms of consequences and likelihood" is the definition of:
(A) Quality
(B) Risk
(C) Safety
(D) Hazard: B
This is a description of risk. As opposed to harm-based prioritization,
RCA2 recom- mends using risk-based prioritization for responding to
adverse events.
5. Which of the following is a helpful tool/method for identifying
underlying causes of problems?
(A) 'Five whys' exercise
(B) Cause and effect diagram
(C) Harm-based prioritization matrix
(D) A and B: D
Cause and effect diagrams and the 'Five Whys' exercise are useful tools
to determine the root cause of a problem. The Safety Assessment Code
Matrix is a method for determining which adverse events warrant close
investigation.
6. What is the ultimate purpose of conducting RCA2 after an adverse
event?
3/7
,(A) Doing a complete and thorough reconstruction of what happened
before the event
(B) Defining what should have happened for the patient
(C) Creating a complete cause and effect diagram
(D) Taking action to reduce the risk of future harm: D
After you identify a safety problem within your system, the only way to
make the system safer and prevent future harm is by taking action. This
is the ultimate goal of RCA2. The other answer options are steps along
to way toward this ultimate goal.
7. Quinn is a three-year-old boy with a congenital heart malformation.
While recovering in the pediatric intensive care unit after surgical
correction, he is accidentally given ten times the appropriate dose of
heparin. Although he
suffers no permanent injuries, the leaders of the hospital decide to conduct
a RCA2. As they assemble the team, which of the following would you
recom- mend?
4/7
,(A) Include Quinn's parents.
(B) Put together a team that mostly includes nurses and physicians.
(C) Create a team of members who fulfill several roles.
(D) Include the health care providers involved in Quinn's care.: C
RCA2 teams need to be diverse in order to be able to see as many
viewpoints as possible. The patient and family, as well as the
providers, involved in the event
should not be included in the RCA2 teams, although they should be
kept informed of the progress. Interprofessional teams are strongly
encouraged, but there is no hard-and-fast prescription for which
professions should be included or what the balance of the professions
should be. Ideally, the team will include people with a strong
understanding of the areas and processes involved in the case.
8. What should leadership teams do to support the RCA2 process?
(A) Make sure there is at least one member of senior leadership on the team.
(B) Wait to conduct the RCA2 review for at least 30 days, to let the
emotions surrounding the incident subside.
(C) Make sure the RCA2 team has designated time to conduct a
thorough review.
(D) All of the above: C
Conducting a high-quality RCA2 review takes time, and leadership
needs to ensure team members have time to devote to RCA2 tasks as
5/7
, part of their work. Senior leadership does not need to be on the core
investigative team; in fact, senior leaders may be an impediment to
drawing candid answers out of front-line staff. RCA2 activities should be
conducted quickly, before memories fade and attention is turned to
newer problems.
9. Which of the following is a method for identifying underlying causes
of specific problems?
(A) 'Five whys' exercise
(B) Swiss cheese model of accident causation
(C) Asking people in the system via 1:1 interviews why they believe an
event occurred
(D) All of the above: A
The 'five whys' exercise is a useful tool to help teams get to the root
causes
of problems by persistently asking "why?". Effective interview
questions focus on identifying what happened, not why. The Swiss
cheese model is a conceptual
6/7
1. RCA2 can be useful in health care because:
(A) It holds people accountable for their actions.
(B) It helps to identify system failures that can be corrected.
(C) It helps to assess the potential risk of introducing a new idea or process.
(D) All of the above: correct answer- B
RCA2 makes health care safer by focusing on systems failures and
improving processes. It does not blame individuals for their actions
and is not a method for enforcing accountability. It is not a method for
assessing the risk of introducing a new idea or process.
2. Mr. Reynolds, a 75-year-old man, recently suffered from a wrong-site
surgery. An RCA2 team is exploring what happened. They consider charac-
teristics of the patient and staff members. According to Charles Vincent,
what other areas should they consider?
(A) Team factors
(B) Work environment
(C) Institutional context
(D) All of the above: correct answer- D
1/7
,The best answer is all of the above. A wide range of factors influence
medical outcomes. Charles Vincent lists seven categories these
factors, including: patient characteristics, task factors, individual staff
member characteristics, team factors, work environment,
organizational and management factors, and institutional con- text.
3. Which of the following scenarios would most likely call for RCA2?
(A) An occupational therapist quits after only three days on the job.
(B) A physician is convinced that there is a better way to deliver pain
medica- tions on her unit.
(C) A social worker catches a patient who is falling out of bed.
(D) An administrator needs to develop a balanced budget.: correct answer-
C
RCA2 is important to address adverse events as well as near misses,
such as the near-fall in answer choice C, that indicate a potential for
harm to patients. Although the other options may represent
opportunities for improvement, they are not indicative of an imminent
threat to patient safety and would not trigger RCA2.
2/7
,4. In regard to RCA2, "The chance of a specific event occurring; measured
in terms of consequences and likelihood" is the definition of:
(A) Quality
(B) Risk
(C) Safety
(D) Hazard: B
This is a description of risk. As opposed to harm-based prioritization,
RCA2 recom- mends using risk-based prioritization for responding to
adverse events.
5. Which of the following is a helpful tool/method for identifying
underlying causes of problems?
(A) 'Five whys' exercise
(B) Cause and effect diagram
(C) Harm-based prioritization matrix
(D) A and B: D
Cause and effect diagrams and the 'Five Whys' exercise are useful tools
to determine the root cause of a problem. The Safety Assessment Code
Matrix is a method for determining which adverse events warrant close
investigation.
6. What is the ultimate purpose of conducting RCA2 after an adverse
event?
3/7
,(A) Doing a complete and thorough reconstruction of what happened
before the event
(B) Defining what should have happened for the patient
(C) Creating a complete cause and effect diagram
(D) Taking action to reduce the risk of future harm: D
After you identify a safety problem within your system, the only way to
make the system safer and prevent future harm is by taking action. This
is the ultimate goal of RCA2. The other answer options are steps along
to way toward this ultimate goal.
7. Quinn is a three-year-old boy with a congenital heart malformation.
While recovering in the pediatric intensive care unit after surgical
correction, he is accidentally given ten times the appropriate dose of
heparin. Although he
suffers no permanent injuries, the leaders of the hospital decide to conduct
a RCA2. As they assemble the team, which of the following would you
recom- mend?
4/7
,(A) Include Quinn's parents.
(B) Put together a team that mostly includes nurses and physicians.
(C) Create a team of members who fulfill several roles.
(D) Include the health care providers involved in Quinn's care.: C
RCA2 teams need to be diverse in order to be able to see as many
viewpoints as possible. The patient and family, as well as the
providers, involved in the event
should not be included in the RCA2 teams, although they should be
kept informed of the progress. Interprofessional teams are strongly
encouraged, but there is no hard-and-fast prescription for which
professions should be included or what the balance of the professions
should be. Ideally, the team will include people with a strong
understanding of the areas and processes involved in the case.
8. What should leadership teams do to support the RCA2 process?
(A) Make sure there is at least one member of senior leadership on the team.
(B) Wait to conduct the RCA2 review for at least 30 days, to let the
emotions surrounding the incident subside.
(C) Make sure the RCA2 team has designated time to conduct a
thorough review.
(D) All of the above: C
Conducting a high-quality RCA2 review takes time, and leadership
needs to ensure team members have time to devote to RCA2 tasks as
5/7
, part of their work. Senior leadership does not need to be on the core
investigative team; in fact, senior leaders may be an impediment to
drawing candid answers out of front-line staff. RCA2 activities should be
conducted quickly, before memories fade and attention is turned to
newer problems.
9. Which of the following is a method for identifying underlying causes
of specific problems?
(A) 'Five whys' exercise
(B) Swiss cheese model of accident causation
(C) Asking people in the system via 1:1 interviews why they believe an
event occurred
(D) All of the above: A
The 'five whys' exercise is a useful tool to help teams get to the root
causes
of problems by persistently asking "why?". Effective interview
questions focus on identifying what happened, not why. The Swiss
cheese model is a conceptual
6/7
